READ: The bad news about Typhoid Fever

Typhoid fever is one of the very deadly infectious diseases common in our environment. It is a disease of poverty but also of ignorance. It is associated with the consumption of food and water contaminated by infected faeces. Such contaminated material is then eaten or drunk and swallowed. In most healthy people, the stomach being very acidic is able to kill off most of the bacteria that cause the disease. In others who are not very fit, the bacteria are able to side-track or overwhelm this line of initial defence and go on to invade the gall-bladder, the vessels conducting lymph through the abdomen. Using those organs as a launch-pad, it invades the remaining parts of the body, thus producing the disease pattern that everyone talks about, but which so many know so few about. In our parlance, it is often said that anyone who has developed typhoid fever must have ‘eaten shit.’

Typhoid is caused by an organism known as Salmonella typhi. There are other similar bacteria called Salmonella paratyphi which nevertheless cause severe disease. These bacteria are found in contaminated water and food as mentioned above. They are also found in poultry products, particularly eggs which even poor people in our environment increasingly eat.

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The different strains of the bacteria can be identified in the laboratory from routine tests so that it is often easy to determine which strain of the bacteria one is dealing with. This disease has a wide variety of symptoms which may present early in the disease or late. Some of these features are headaches, joint and muscle pains, constipation followed in a few days by diarrhoea. There may also be the appearance of red spots on the trunk called rose spots because of their characteristic redness. Fever, abdominal pain and vomiting are also features of this disease.

The constellation of these features often force even the most recalcitrant to go to the hospital where confirmatory tests are done to determine the presence of this disease. The fever has a step-ladder pattern so that it shows an uneven rise when charted that resembles a staircase. Headaches are throbbing and severe with occasionally blurred vision. Stooling and vomiting may be so severe that people collapse. The commonest test performed in many parts of the country is the Widal reaction which is often useless unless it is done in a series that can clearly demonstrate a rise in the titres measured against the various types of the offending bacteria. It is more useful, more reliable to have urine and stool cultures done in the second and third weeks respectively which if positive will conclusively diagnose the disease. Routine blood tests will typically show a reduced blood count and surprisingly, a reduction in the white blood cell count as opposed to an increase that holds true for nearly all severe infections. The heart rate often fails also to rise in a measure commensurate with the severity of the disease. When all these features are put together, a diagnosis is made with a fair amount of certainty.

The disease itself can be quite debilitating. It can linger in the blood for several weeks and would require energetic treatment to get it over with. It can cause a significant reduction in the blood volume. It can ascend into the brain and cause what is known as typhoid psychosis during which phase the patients become violent and talkative and sleepless with an aversion for food. It can spread into the bones and cause chronic infections particularly in people with sickle cell disorder. It can similarly invade the gall-bladder causing severe infection there that may threaten life. It can cause the intestines to perforate, thus spilling their load of stool into the abdomen. Many such people would be dead in a short while without emergency surgery. The abdomen gets quite big and also tense so much so that they are unable to breathe well. It can similarly cause fluids to accumulate within the lungs and even inside the sac surrounding the heart, thus compressing it.

All these problems bring us to the current issue regarding why this disease is poised to become an even bigger problem. Many people in the length and breadth of Nigeria and elsewhere in West Africa do not have access to safe drinking water. Many people also do not properly store their food. To make matters worse, many people who are on treatment for typhoid do not truly have the disease. In the meantime, however, they would have been placed on potent antibiotics such as Ciprofloxacin; Amoxycillin-Clavulanic acid combinations; Perfloxacin; Azithromycin and Cotrimoxazole by all players in the health care system from the dispensing chemist through the auxiliary nurse to the bored doctor who wishes to be rid of the troublesome patient by giving him a prescription so he can be left alone. The resulting abuse and misuse of antibiotics are sure to impact negatively in our communities. The result has been a steady rise of multi-drug resistant strains of the salmonella organism. For now, there are an estimated 21.5 million typhoid infections annually in Africa and Asia with about 200,000 deaths. Most of these victims are in Sub-Saharan Africa. Many of them are children who tend to fare the most badly in the various communities.

The arrival of the drug resistant strain of this deadly infection is sure to spike this mortality rate. To make matters worse, the typhoid vaccine is not widely available. Where it can be found, its effectiveness is spotty and unreliable beyond two or three years. In a general atmosphere of civil strife as represented by Boko Haram in Nigeria, Cameroon, Niger and Chad; the Islamist rebellion in Mali and the civil war in the Central African Republic, such problems are guaranteed to rise. Even in reasonably stable nations on the continent, the absence of relevant infrastructure, the dearth of potable water and the paucity of adequate health care facilities are certain to worsen the general picture. For us here in Nigeria, we must prepare for an upsurge in the number of complicated cases of typhoid we see in our communities and also in the number of fatalities related to the disease. The currents antibiotics in use against the disease will soon, like it happened in malaria before, become unsuitable for the treatment of the condition. We will then be forced to use drug combinations and new products which may be less reliable than what is now available. To be sure, the creeping development of drug resistance in the treatment of typhoid has not just begun nor has it been unrecognised before now; it is just that the pace of its development has quickened in the last 10 years and it is worsening.

Efforts must therefore be doubled to provide safe drinking water to the largest number of people possible with the commitment and political will that such an effort requires. The diagnosis of typhoid fever ought to be taken more seriously than what we now experience and the indiscriminate use of antibiotics by all and sundry must be somehow curtailed by more firmly controlling the availability of the various compounds. It is only by a strict regulation of these areas of permissiveness that this serious infection like others before it can be brought under effective control. In our individual dwelling places, we need to be aware of these problems, keep clean in our eating habits and cook our food properly before eating. Let us also resist the temptation of reaching for any of the antibiotics named above simply because we have the means to get them while acting essentially on a mere suspicion.

- Dr. Sylvester Ikhisemojie/Punch

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